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Patient Controlled Analgesia: Patient Controlled Analgesia: More than twentyMore than twenty‐‐five years in the five years in the
making: making: Where are we now?Where are we now?
ASPMN 19th National ConferenceASPMN 19th National Conference
Jacksonville, Florida
September 15th 2009
Sheryl Redlin Frazier, RN, MSN, OCN® &Sheryl Redlin Frazier, RN, MSN, OCN® &Mark Sullivan, PharmD, MBA, BCPSMark Sullivan, PharmD, MBA, BCPS
Goals and Objectives
• Describe quality improvement models for PCA and the role of nursing and pharmacy in these models
• Discuss pain management in the acute care p gand ambulatory environment
• Integrate the management of risks associated with PCA use and adequacy of analgesia
• Identify the features of PCA technology that impact nursing workflow and methods for reducing errors
History of the PCA
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• IM to IV• Medications used for analgesia• Intermittent IV bolus by nursing
Evolution of analgesic delivery
• Intermittent IV bolus by nursing• Development of the delivery device• First pumps in use
Pump technology development timeline
?
PCA ‐ In the beginning…• Roe 1963‐ small IV doses of opioids = increased efficacy
• Forrest 1970 – Demand Dropmaster
• Sechzer 1968 1971 – RN administered doses on• Sechzer 1968, 1971 RN administered doses on patient demand, then by pump
• Keeri Szanto 1974 – Demanalg pump
• “Cardiff Palliator” 1976 1st commercially available PCA pump – Welsh National School of Medicine
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2nd wave of Technology1984 PCA introduced for hospital setting
– First self contained device allowing the patient to self administer their own pain medication
– Automated settings allowed:• PCA dose from 0.1 to 5.0ml in 0.1ml increments
• Loading dose options from 0.1 to 9.9 ml in 0.1 ml increments
• Lockout intervals from 5 to 99 minutes in 1 minute increments
– Used commercially available syringes that decreased compounding errors.
Cardiff Palliator
1st Generation PCADevices
On-demand analgesia computer
Abbott LifeCa e
Harvard PCA
Prominject
Abbott LifeCare
2nd Generation PCA Devices
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2nd wave of Technology• Integration of bar code technology
– Built into the pump or integrated with device– Ability to read vendor generated or custom barcodes
• Concept of combination therapyE h d d f d li B l O l d– Enhanced modes of delivery: Bolus Only and Continuous + bolus
• Increased drug and concentration options• Transaction logs retained in device• Chronological record of most recent events
– Allows review at bedside of previous shifts administration
2nd wave of Technology• Expanded capability to utilize
pharmacy filled vials– Allowing pharmacy to use custom filled empty sterile vials • utilize manufacturer pre‐filled• utilize manufacturer pre‐filled vials ( ~18 months expiration)
– Pre‐filled vials with bar coded & color enhanced labels to aid in the readability of drug and drug concentrations
– Ability to utilize dispensing cabinets
3rd wave of technologyIntroduction of Safety Software with wireless/wired connectivity• Rule Sets / Profiles
• Hard / Soft dosing limits configurable for each medication
• Safety programming• Final Confirmation Screens• Ergonomic design for safer use
• Wireless functionality allows ease of data transfer from pumps• Infusion data at a glance• Alarms/Events• Asset tracking functionality• Validation of compliance with policy use
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Shift control from provider to patient
• Prior to 1960’s; injectable pain medications given IM; morphine used for surgical anesthesia during Civil War with advent of the hypodermic needlethe hypodermic needle
• Efficacy of small IV doses of pain medication proven in 1960’s
• Delicate balance of patient assessment & adequate analgesia; response to Nurse call; dose administration a challenge
Shift control from provider to patient
Advent of PCA technology allowed transition of control to the patient• Enhanced Quality of AnalgesiaEnhanced Quality of Analgesia• Benefits of Control
• Barriers to PCA
• Care givers barriers and biases
Pain Management with PCA
Acute Care Setting• Acute Pain
• Surgical
•Non surgical
• Chronic Pain
• Cancer Pain
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Pain Management with PCA
Special Populations• Pediatrics
• Geriatrics
• Oncology
Pain Management with PCA
Ambulatory Care• Duration of use
f d l d• Type of delivery device•Disposable vs Non disposable
• Evolving technology • Transdermal delivery systems
Pain Management with PCA
Ambulatory Care•Chronic Analgesia
•Multimodal therapies
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Pain Management with PCA
Pharmacology – long acting opioids• Morphine
d h• Hydromorphone
• Meperidine
Pain Management with PCA
Pharmacology – short acting opioids• Fentanyl
f l• Remifentanyl
• Sufentanyl
Pain Management with PCA
Pharmacology – non opioids• Nonsteroidal agents
h• Anesthetics
• Other
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Non‐pain uses of PCA
• Antiemetics
• Supportive therapies
Assessment of the PCA patient
Adequacy of pain management• Pain scales
• Patient EducationPatient Education•Pain reassessment
•Response to inadequate treatment• Escalation of therapy
Assessment of the PCA patientSide effects
• Respiratory Depression•Monitoring•TreatmentTreatment
• Nausea/vomiting•Monitoring • Treatment
• Itching• Delirium
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Assessment of the PCA patient
Care of the complex patient
• Pediatrics
• Geriatrics
Assessment of the PCA patient
PCA surrogacy•PCA relies on negative feedback looploop•If too sleepy, can’t push the button
•Pediatrics•ISMP assessment
•PCCU assessment
Assessment of the PCA patientPCA surrogacy
• Adults• Lock out mode as a safety feature
Balance of treatment efficacy vs side effects• Utilization of multimodal therapy
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Assessment of the PCA patient
Utilization of multimodal therapy•Management of the complex patient
•Dosing•Dosing
•Delivery•Matching opioid demand to pump delivery capabilities
Multidisciplinary approach to pain management
• Purpose of gathering the team:– Explain the technology & pharmacology
– Develop objectivesDevelop objectives
– Plan enduring training for all caregivers• Orientation
• Yearly competencies
• Web‐based or hands‐on or both
• Remediation
Implementation of smart pump technology
• Steering committee
• Interdisciplinary effort• RFI – functionality, integration, safety
• Order Sets, CPOE
• Drug library creation•Translation of order sets, drug information
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Implementation of smart pump technology
Drug library creation•Translation of order sets, drug information
• Linkage between drug files and bar codes• Linkage between drug files and bar codes
•Allowance for wild card settings
•Hard stops vs soft stops
• Lockouts
Implementation of smart pump technology
Drug library creation•Definition of special populations
• Adults• Adults
• Pediatrics
• Opioid naïve
• Opioid tolerant
• Sickle Cell crisis
• Crisis
Implementation of smart pump technology
Drug library creation•Staff Training
b l•Web tools
•Hands on
• Simulation
• Enduring training
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Monitoring of smart pump technology
Quality Improvement:• Wireless functionality = data transfer
• Data to the pump• Data to the pump
• Data from the pump
• Patient assessment = profile selected = dosing
Monitoring of smart pump technology
Integration with clinical systems• Closed loop with CPOE/Pharmacy
• Automated initial programmingAutomated initial programming
• Closed loop with Nursing documentation systems• Automated treatment programming based on assessment based on EBM algorithm
Conclusions
• Remember impacts of People, processes, and systems
• Structure to maintain communication• Literature of pain management ever changing
• Focus on the patient and best treatment
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References
References used in this presentation are available on a separate handout.
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